**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent resident to resident abuse for 1 (R2) of 3 residents reviewed for abuse in a sample of 26. This failure resulted in R2 being pushed down and verbally threatened by R1 and R2 being fearful of R1. Findings include: R1's admission Record documents and admission date of 4/21/23 with diagnoses including: dementia with unspecified severity with agitation. R1's New admission Information Sheet documents a diagnosis of Dementia with Behavior. R1's Diagnosis Sheet (undated) documents a diagnosis of: dementia with aggressive behavior. R1's care plan documents a focus area of: the resident (R1) has potential to be physically aggressive to staff and other residents r/t (related to) dementia with a revision date of 07/18/24. The interventions listed include: administer medications as ordered; monitor/document for side effects and effectiveness; analyze times of day, places, circumstances, triggers, and what de-escalate behavior and document; assess and address for contributing sensory deficits; assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain and etc. (et cetera); communication: provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of resident posing danger to self and others; psychiatric/psychogeriatric consult as indicated; and when the resident becomes agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. All interventions are dated 06/27/2024. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 02, indicating R1 has severe cognitive impairment. Section E, Behaviors, under Behavioral Symptoms documents that physical behavior symptoms directed towards others occurred 1 to 3 days during the assessment period. R1's Behavior Tracking Record dated September 2024 documents target behaviors of agitation and aggression. A 0 is documented on all days through 9/26/24, including 9/24/24, indicating R1 had no behaviors. R1's Nurse's Notes dated 09/24/24 at 6:45 AM documents: resident was involved with peer on peer with other resident. This resident was the aggressor. (R1) pushed other resident, hit her and knocked her down to the floor and stated, I'm going to kill you. R1's Nurse's Notes dated 09/24/24 at 6:55 AM documents: spoke with (psychiatric office) new order to send resident to ER (Emergency Room) for psychiatric evaluation. R1's Emergency Department Notes from the local hospital dated 09/24/24 documents a Chief Complaint of Aggressive Behavior. A provider notes dated 9/24/24 at 7:50 AM documents presents to ED (Emergency Department) from (name of facility) for aggressive behaviors. Calm and docile for EMS (Emergency Medical Services). NH (Nursing Home) reports he had an altercation with a female resident in the facility. R2's Physician Order Sheet dated 09/01/24 to 09/30/24 documents a diagnosis of dementia dated 12/09/23. R2's MDS dated [DATE] documents a BIMS score of 03, indicating R2 has severe cognitive impairment. R2's Nurse's Notes dated 09/24/24 at 6:45 AM document: CNA (Certified Nurse Aide) yelling from dining room, this writer (V4-Registered Nurse) ran to the dining room to find resident on the floor with another resident standing up. CNA stated he hit her and pushed her over. Housekeeping saw resident go down and wrote a statement. Resident peer stated I'm going to kill you when resident went down she fell on her right side - arm, elbow, hip and face. R2's ED (Emergency Department) nurse timeline notes from the local hospital dated 09/24/24 at 8:20 AM documents: patient presents with right arm/leg pain after another resident pushed her down. At 8:50 AM the notes document: slight grimace with movement of right knee and right elbow. R2's Hospital notes dated 09/24/24 documents: final diagnoses: contusion of right elbow; unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; pain in right knee; headache; and cervicalgia. On 09/27/24 at 8:40 AM, R2 stated she was scared. When asked why, R2 stated because of the fight. R2 then stated, that man, he's mean. On 09/27/24 at 10:12 AM, V4 (Registered Nurse) stated that R1 can be nice and then all of the sudden something can agitate him and he can become aggressive. She was working when the peer to peer incident happened between R1 and R2. V23 (Housekeeping) witnessed the event and yelled for assistance. She made the report, assessed the residents and sent them out for evaluation. On 10/01/24 at 2:10 PM, V18 (Certified Nurse Aide) stated she saw R2 later in the day on 09/24/24 after she returned from the hospital. V18 stated that R2 could not specify where she was hurting but she was trying to tell her about the incident. On 10/01/24 at 1:45 PM, V23 (Housekeeping) stated that she was in the hall cleaning looking in the dining room when the incident between R1 and R2 happened. R1 and R2 were sitting at the same table when R1 got up abruptly and went over to R2. R2 stood up from her chair and R1 started yelling at R2. R1 then hit R2 and pushed R2 down. She ran over to them to try to keep R2 from hitting her head and yelled for help at the same time. There was no other staff in the dining room, the nurse on duty was at the nurse's station and the CNA's were assisting other residents. V23 stated, R2 was scared and complained her arm and leg were hurting. A final investigation report received by the Illinois Department of Public Health from the facility from V1 (Administrator) on 9/27/24 documents On 9/24/24 at approximately 6:50 AM, it was reported to this administration by (V3-Assistant Director of Nursing) that an alleged peer to peer incident happened between (R2) and (R1). The report further documents that (V23-Housekeeper) stated that she was in the dining room and looked up to see (R1) standing from his seat and he began to yell towards (R2). (R2) then stood from her chair and (R1) moved towards her and pushed her to the floor while telling (R2) that he wanted to kill her. (R2) then said that she was scared. The report concludes the facility can substantiate that no injuries occurred following the interaction between (R2) and (R1). The facility policy, dated 11/28/16, titled Abuse Policy and Procedures documents in part: this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident ' s medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by: dementia management and resident abuse prevention.

Based on interview and record review the facility failed to notify a resident's physician for a fall with injury in a timely manner for one of three residents (R1) reviewed for falls in a sample of 7. This failure resulted in delayed treatment for R1's impacted distal radius fracture and ulnar styloid fracture of the right wrist. Findings included: According to R1's admission Face Sheet and Cumulative Diagnosis sheet, R1 was admitted to this facility on 12/7/2022 with the diagnoses of Severe Dementia associated with Alcoholism without behavioral Disturbance, Psychotic Mood Disorder, and Anxiety. R1's MDS (Minimum Data Set) dated 12/18/2023, documented an attempt to assess R1 using the BIMS (Brief Interview for Mental Status) test, but R1 was unable to perform the test due to rarely or never understood and thus had no score out of 15 total indicating R1 has severe cognitive impairment. This same MDS documented R1 is independent with walking, transferring, does not use a wheel chair and has no impairment to upper and lower extremities. On 4/11/2024 at 9:22am, V6 (Certified Nursing Assistant/CNA) said on 3/31/2024 she was working R1's unit the evening R1 fell out of bed. V6 said at around 10:00pm, she was up at the nurses station, which is close to R1's room, when she heard a loud thump and went to check on R1. V6 said she found R1 sitting on the floor next to her bed. V6 said R1 told her she was ok so she helped R1 back into bed and went to report the fall to the nurse (V5) and V5 came to see R1 immediately. On 4/11/2024 at 8:45am, V5 (Licensed Practical Nurse/LPN) said on 3/31/2024, she and V6 were working on R1's hallway when R1 fell out of bed and hurt her right wrist. V5 said she assessed R1 and did not find any injuries to R1's body except R1's right hand/wrist was very bruised and swollen. V5 said she contacted R1's family to report the fall and injury. V5 said she tried to contact R1's doctor all night, but did not get an answer. V5 said she did not send R1 to the local emergency room and thought the next shift (day shift) would notify the doctor of R1's fall and injury to right wrist/hand and get treatment for R1. On 4/11/2024 at 11:26am, V11 (LPN) said she worked the dayshift on 4/1/2024 and 4/2/2024 but did not remember being told in report about R1's fall and right wrist/hand injury, bruising and swelling and thus did not continue to attempt to notify R1's doctor on either day. V11 said it is so hectic and loud on the dementia unit that she has trouble concentrating. V11 said the facility was not short staffed and she feels adequately trained, but has only worked at this facility for about 3 months. V11 said on the morning of 4/1/2024, R1 came to her and showed her the injured wrist, but V11 did not catch what R1 was trying to tell her. V11 said on 4/2/2024 at 12:00pm, during the noon meal, V18 (Social Service Director) was the first staff to notice R1's right hand was injured and asked V2 (Director of Nursing/DON) to take a look at it. V11 said she was too busy to contact R1's doctor until around 3:00pm when she sat down to chart at the nurse's station. V11 said at 3:00pm, she notified V14 (Nurse Practitioner) of R1's right wrist/hand injury with swelling and bruising. A Social Service Progress Note in R1's medical record dated 4/1/2024 documented by (V18/Social Service Director/SSD) the following: Was told in morning meeting the resident (R1) had fallen out of bed. After morning meeting I sat down with resident in her room. She claims it doesn't hurt Not really is what she said. Couldn't explain what happened to me. Only said It just happened yah know. A Nurse's Note in R1's medical record and dated 4/1/2024 (actual date of entry 3/31/2024) documented V5 called R1's doctor at 10:45pm, 11:20pm and on 4/1/2024 at 4:15am, but the doctor's phone continued to have a busy signal every time V5 called. A Social Service Progress Note in R1's medical record dated 4/2/2024 by (V18/Social Service Director/SSD) documented the following: Writer noticed residents (R1) Rt (right) arm bruised, hand/palm swollen. I (V18) reported this to DON (Director of Nursing-V2). She immediately when (sic) down to resident's room. Xray was ordered (mobile x-ray service name). After results was taken to ER (Emergency Room) Returned with temp (temporary) cast . A Nurse's Note in R1's medical record entered by V2 (DON) on 4/2/2024 at 12:40pm documented the following: Request from SS (Social Services) to check residents R (right) arm, has bruising and R (right) hand palm is swollen. Resident c/o (complained of) pain when hand touched, but could not rate pain. Will contact NP (Nurse Practitioner). A Nurse's Note in R1's medical record entered by V2 on 4/2/2024 at 1430 (2:30pm) documented the following: Clarification of R (right) forearm discoloration. Dark bruising vertical marks with yellow discoloration around the wrist area. Palm of the hand is discolored also (dark). (R1) has no recall of hurting her arm. A Nurse's Note in R1's medical record by V11 (LPN) on 4/2/2024 at 3:00pm documented the following: Resident noted to have bruising at different stages to the R (right) wrist and to R (right) forearm. Notified mother who states res. (resident) has had a cast in the past and will not leave it alone, that she will work it off. Notified provider (V14 /Nurse Practitioner) via (name of messaging service used to communicate with providers) with pictures . A Nurse's Note in R1's medical record by V11 (LPN) on 4/2/2024 at 6:30pm documented the following: (mobile x-ray service providers name) personnel here (at facility) to do x-ray to R (right) forearm. The x-ray service provider results for R1 dated 4/2/2024 documented the following: Procedure-Right Forearm, 2 views, Findings-an impacted distal radial fracture is identified. The fracture does not involve the articular surface. An ulnar styloid process fracture is also noted. Moderate degenerative changes are present. The remaining osseous structures are intact. R1's ED (Emergency Department) Physician Documentation from the local hospital dated 4/3/2024 documented the following in part: This patient presents from the nursing home with diagnosis of an impacted distal radius fracture and ulnar styloid fracture of the right wrist. This was sustained in a fall yesterday. A Nurse's Note in R1's medical record by V5 (LPN) on 4/3/2024 at 4:40am documented the following: Rec'd (received) stat x-ray results #1 R (right) wrist fx (fracture), #2 R (right) forearm fx (fracture), #3 R (right) hand fx (fracture). A Nurse's Note in R1's medical record by V5 (LPN) on 4/3/2024 at 4:45am documented the following: Called (name of on call doctor) TO (telephone order) to send resident (R1) to ER (emergency room) for eval (evaluation) and Tx (treatment). On 4/11/2024 at 12:39pm, V2 (Director of Nursing/DON) and V3 (Assistant DON) were interviewed at the same time and both agreed R1's doctor was not notified of R1's injuries and fall in a timely manner and that it should not have taken 2 days to begin providing R1 care of her injured right wrist/hand that was determined 2 days later to be a fractured right wrist. V3 said when R1's doctor could not be reached, V5 (LPN) should have sent R1 to the local emergency room for evaluation of her right wrist/hand injury at the time the injury was first discovered. V2 said V11 (LPN) should have continued to reach R1's doctor but failed to do so. V2 said the facility does not have a policy on what the nursing staff should do if they cannot reach the resident's doctor in a timely manner, but they will look into getting one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to fully investigate resident falls, failed to perform a root cause analysis of the falls, and failed to develop and implement appropriate interventions to prevent future falls for 3 of 13 residents (R21, R2, and R27) reviewed for falls in a sample of 31. This failure resulted in R21 falling and sustaining a facial laceration with sutures, nasal bone fractures, and a nondisplaced fracture of the left middle finger. Findings include: 1. R21's New admission Information Sheet documents an admission date of 05/15/2019. R21's Cumulative Diagnosis Log (undated) documents diagnoses including: Advanced Dementia, Altered Mental Status, Alzheimer's Disease, closed fracture of ramus of right pubis, closed compression fracture of body of L1 vertebra, closed left arm fracture, and Pelvic ring fracture, decreased Mobility. R21's MDS (Minimum Data Sheet) dated 12/04/23 documents no BIMS (Brief Interview of Mental Status) was conducted due R21 is rarely understood. R21's Fall Risk assessment dated [DATE] documents a score of 15, this document notes 10 points or more = high risk score. The facility document titled. Fall Analysis Log dated February documents R21 had falls on 2/12/24, the one dated January notes a fall on 01/28/24, the one dated November notes a fall on 11/05/23 and the log dated October documents falls on 10/15/23, 10/21/23, and 10/23/23. On 03/06/24 at 10:30 AM, V1 (Administrator) stated the documents titled, Quality Improvement Review are the fall investigations for the residents. R21's Quality Improvement Review dated 02/12/24 at 8:30 AM documents: Resident (R21) was observed walking in the hallways. She was wearing her non-skid socks. She (R21) was then noted sitting on her buttocks in the hall. No environmental issues noted. Resident (R21) has decreased safety issues and will reach out for others. Assessed at the ER (Emergency Room). (R21's) BIMS (Brief Interview of Mental Status) is 3. Intervention is to have 15 minute visual checks and frequent monitoring. On 03/07/24 at 2:00 PM, V1 (Administrator) stated, from that fall investigation (fall occurring on 2/12/24) she could not tell what the root cause of the fall was, if R21 was injured, what an appropriate intervention would be and there was no interviews done in relation to the fall from other residents or staff. R21's Nurse's notes dated 02/12/24 at 6:15 PM documents noted res (R21) sitting upright on floor in hallway. Raised goose egg erected to left forehead. The area is purple and bleeding. R21 moves head and neck freely. C/O (complaints of) pain to left forehead only. ROM (Range of Motion) WNL (Within Normal Limits) for this resident. Assist res (resident) to stand. Ambulated to her own room (without) difficulty. Continue to require pressure to forehead d/t (due to) continued bleeding. R21's Nurses Note dated 2/12/24 at 6:45 PM documents called EMS (Emergency Medical Service) for request to transfer. R21's Nurse's notes dated 02/13/24 at 1:35 AM documents: Resident (R21) returned to facility per wheelchair and staff. R21 is cheery and slightly confused, she has a dressing to her forehead containing 2 to 3 sutures. R21's hospital records dated 02/12/24 document: Diagnosis: Unspecified injury of head, initial encounter; Laceration without foreign body of other part of head. Discharge Instructions: Head injury, Facial Laceration. Follow up instructions: Reason: staple/suture removal, return to ED (Emergency Department) or have sutures removed by your physician in 5-7 days. R21's Quality Improvement Review dated 01/28/24 at 8:35 AM documents: This resident (R21) was ambulating in the hallway before this event occurred. She has complaints of aching afterward. She has decreased safety awareness and her BIMS is 3. The intervention is to educate staff on checking residents for proper footwear/non-skid socks, monitor frequently and encourage resident to ask for assistance/offer assistance. On 03/07/24 at 2:00 PM, V1 (Administrator) stated, from that fall investigation (fall occurring on 1/28/24) she could not tell what the root cause of the fall was, if R21 was injured, if she was sent out for evaluation, if that was an appropriate intervention for this fall and there were no interviews done in relation to the fall from other residents or staff. V1 stated, R21 would be assisted with her footwear by staff and R21's care plan documents an intervention on 10/23/23 of: R21 to wear nonskid socks during ambulation on the unit, so that would also be a duplicate intervention. R21's Nurse's notes dated 01/28/24 at 9:25 AM document: Resident (R21) fell in hallway in a cubby area where she was not seen. Another resident found her and reported it to one of the aides. She was found sitting up leaning on the wall, blood coming from her nose, hematoma on her forehead on the right side. She has a laceration on her nose. R21 states she does not know what happened. R21 was sent to ER for evaluation. R21's Social Service Progress Notes dated 01/29/24 document: Resident (R21) fell yesterday 01/28/24. Another resident found her and reported it. She was bleeding from the nose. Sent to ED. R21 has a broken nose and bruising all over face. R21's Social Service Progress Notes dated 02/01/24 document: Resident (R21) still has bruising on her face. Says it hurts a little but not complaining. Ambulates around on her own and can have an unsteady gait from time to time. Can communicate but jumble words when speaking. She can still make her needs known. BIMS 3, her focus isn't the best. R21's Nurse's notes dated 01/30/24 at 8:48 AM document: Bruising noted to both sides of face. R21's Emergency Department records dated 01/28/24 document: CT (Computed Tomography) Maxillofacial: There are bilateral mildly depressed nasal bone fractures. There is chronic appearing rightward deviation of the nasal septum, however there is also likely a mildly displaced fracture through the posterior septum with 2 to 3 mm (millimeters) displacement. Impression: 1. Right frontal scalp hematoma. No acute intracranial abnormality. 2. Bilateral mildly depressed nasal bone fractures. 3. Probable mildly displaced fracture through the posterior nasal septum. R21's Quality Improvement Review dated 11/05/23 at 4:15 PM documents: Resident (R21) was ambulating in the east dining room with her non skid socks on. She appeared to trip before this event. She was seen in the ER for complaints of left hand wrist discomfort. She has decreasing safety awareness. Intervention is to have a PT (Physical Therapy) evaluation. On 03/07/24 at 10:30 AM, V24 (Physical Therapy Director) stated R21 was already receiving occupational therapy from 10/11/23 to 12/06/23 and physical therapy from 11/15/23 to 12/29/23. R21's Nurse's notes dated 11/05/23 at 4:15 PM documents: R21 was seen tripping over another resident's chair and fell to the floor. R21 attempted to catch self resulting in skin tear on left hand and left middle finger. Complaints of pain to left hand and steri strips applied to areas on hand. At 4:30 PM R21 will not sit down in dining room, continues to wander. Multiple attempts have been made by staff to help direct resident to seat. R21's Nurse's notes dated 11/5/23 at 9:09 PM documents that R21's middle finger on left hand is blue inf color and R21 was sent to the local hospital for evaluation and treatment. R21's Nurse's notes dated 11/05/23 at 8:49 AM document: Resident (R21) in room for breakfast. She sat up on the side of the bed to eat breakfast tray. R21 took AM medications with difficulty. Bruising and swelling noted to R21's left hand. On 37/24 at 11:00 AM, V8 (Licensed Practical Nurse) stated, she would have to guess the note dated 11/05/23 at 8:49 AM should be 11/06/23 at 8:49 AM. R21's Hospital notes dated 11/05/23 document: Diagnosis: Fall on same level, unspecified, Contusion of other part of head, contusion of hand. Discharge instructions: Hand contusion, Head injury. R21's Nurse's Note dated 11/8/23 at 11:25 AM documents New x-ray orders for L (left) hand and wrist. R21's Nurse's note dated 11/9/23 at 9:50 AM documents Received results of X-ray on 11/8/23, NP (Nurse Practitioner) notified and wanted her sent to ER (Emergency Room). She was sent to (name of local hospital) ER. Before leaving she c/o mild pain and not being able to move fingers on L hand. No c/o pain anywhere else besides her hand. Currently at ER (with) CNA (Certified Nurse's Assistant) from facility. R21's Hospital notes dated 11/09/23 document: Diagnosis: Non-displaced fracture of distal phalanx of left middle finger. Discharge Instructions: Finger Fracture; Follow up instructions: When - 5 to 6 days, reason - worsening of condition; Recheck today's complaints. R21's Imaging Report dated 11/9/23 documents: Exam Reason: pain with trauma/injury. Discussion: The bones are diffusely demineralized. There is possible recent intra-articular fracture involving the proximal aspect of the third digit middle phalanx. Which can be correlated with the clinical situation. Osteoarthritic changes are most severe in the first carpometacarpal joint region. Impression: 1. Possible recent fracture involving the proximal aspect of the third digit middle phalanx, can correlate with the clinical situation. Emergency Department records dated 11/9/23 note: at 11:06 AM This [AGE] year old white female presents to ER with complaints of fall injury. 11:06 AM The patient (R21) or guardian reports injury. The complaints affect the left hand diffusely. Context: The problem was sustained at a nursing home or assisted living facility, resulted from a fall. Onset: The symptom(s)/episode began/occurred acutely. Modifying factors: the symptoms are aggravated by movement. Associated signs and symptoms: Pertinent positives: swelling, Severity of symptoms: in the emergency department the symptoms are unchanged. It is unknown whether or not the patient has had similar symptoms in the past. It is unknown whether or not the patient has recently seen a physician, [AGE] year old lady with Dementia who sustained injury to left hand from a ground level fall a few days ago. She has no other complaints. She has associated swelling of the digits. She denies headache, denies neck and back pain. Diagnosis: Nondisplaced fracture of distal phalanx of left middle finger. R21's Quality Improvement Review dated 10/23/23 at 4:15 PM documents: Resident (R21) has independent ambulation and decreased safety awareness. She was in the east dining room but had removed her nonskid socks when this event occurred. R21's BIMS is 3. Intervention is to educate staff to encourage resident to put her socks on and leave socks on for safety when walking. R21's Nurse's Notes dated 10/23/23 at 4:15 PM document: R21 was on the floor in dining room. R21 was sitting on her bottom in front of the table she had been sitting at. R21's Nurse's Notes dated 10/24/23 at 12:00 AM documents: R21 is up to Nurse's station with complaints of right rib cage pain and bruising noted. R21's Quality Improvement Review dated 10/21/23 at 3:38 PM documents: Resident (R21) has decreasing safety awareness and independent ambulation. She was in the east dining room and appeared unsteady. She was wearing her nonskid socks. She has a BIMS of 3. Intervention for this event is to have a therapy evaluation. R21's Nurse's Note dated 10/21/23 at 4:00 PM documents: Resident (R21) found on the floor by another resident's family. R21 stated, that man pushed me however the man that she was pointing to was a female. A male resident was witnessed attempting to help R21 from the floor and a female resident was hovering behind her. The family member of the other resident helped R21 from the floor and brought her to the nursing station. X-ray of right shoulder, wrist and hip were ordered and awaiting approval. R21's Patient Report from the mobile X-Ray company dated 10/22/23 document Reason: Fall on right side with pain within the shoulder, wrist and hip areas. Findings: No acute fractures or dislocations are noted. Chronic fracture deformity of the distal radius is identified. An ulnar positive variance is noted. Moderate degenerative changes are present. The surrounding soft tissues are normal. On 03/07/24 at 2:00 PM, V1 (Administrator) stated, from the 10/21/23 fall investigation she could not tell what the root cause of the fall was, if R21 was injured, what an appropriate intervention would be and there was no interviews done in relation to the fall from other residents or staff. She stated from the fall investigation it sounded like the fall was witnessed but the nurse's notes stated she was found by another resident's family member, which strongly suggests it was an unwitnessed fall. V1 stated, she does not know why the intervention was to have a therapy evaluation, since she was already on therapy. The intervention of wearing nonskid socks during ambulation would not be helpful when the Quality Improvement document states she has them on. On 10/15/23 at 6:15 PM R21's Quality Improvement Review documents: This ambulatory resident (R21) was observed in the bathroom. She was trying to use the bathroom by herself. She did have her gripper socks on and was sitting on her buttocks in front of the stool. No environmental factors. R21 is on antidepressant medications and antihypertensive medication. She has decreasing safety awareness. Intervention is to educate staff to encourage resident to ask for assistance in the bathroom. There is no documentation of this fall in the nurse's notes. On 03/07/24 at 2:00 PM V1 (Administrator) stated, from that fall investigation (for the fall occurring on 10/15/23) she could not tell what the root cause of the fall was, if R21 was injured, what an appropriate intervention would be and there was no interviews done in relation to the fall from other residents or staff. V1 stated with R21's cognition level she would not remember very long to ask for assistance in the bathroom, so that is not an appropriate intervention. V1 stated, R21's MDS (Minimum Data Set) documents she is assessed as needing assistance to the toilet and supervision with locomotion. R21's MDS dated [DATE] documents toilet use: Limited assistance - resident highly involved in activity, staff provide guided maneuvering or limbs or other non-weight bearing assistance with one person physical assistance, and for locomotion on unit as supervision - oversight, encouragement or cueing with setup help only. R21's care plan with a category of Falls documents: Resident (R21) has periods of poor safety awareness where she does not pay attention to surroundings and location of objects around her. Risk factors include: forgetfulness and episodes of confusion and poor safety awareness. Current cognitive level is alert and oriented x3 with episodes of forgetfulness with a start date of 08/16/21. Interventions documented include: Remind of safety precautions and limitations as necessary with a start date of 08/16/21, frequent reorientation and reminders on location of room and surrounding with a start date of 08/16/21, staff are to assist resident to bathroom during HS (evening) and when they see resident attempting to use restroom without assistance. PT/OT (Physical therapy/occupational therapy) to evaluate for safety and gait training. 10/23/23, resident unsteady with gait. Will have therapy see if can do evaluation with a start date of 10/27/23, and R21 had fallen due to other resident's chair, balance and weakness noted and will benefit from therapy evaluation with a start date of 11/10/23. There is no documentation on R21's Care Plan for interventions implemented after R21's fall on 10/15/23 and 1/28/24. 2. R2's New admission Information sheet documents R2 has an admission date of 04/22/19. R2's Cumulative Diagnosis Log documents diagnoses including: Dementia, Generalized anxiety disorder, Alzheimer's disease, Irritable Bowel Syndrome, and Macular Degeneration. R2's Minimum Data Sheet dated 10/9/23 documents active diagnoses including: Unsteadiness on feet, Muscle Weakness, and other Reduced Mobility. The facility document titled Fall Analysis Log dated February 2024 documents R2 had falls on 2/1/24, 2/13/24, and 02/14/24. The January 2024 Fall Analysis Log documents that R2 had falls on 01/08/24, 01/13/24, and 01/29/24. The November 2023 Fall Analysis Log documents that R2 had falls on 11/02/23, 11/07/23, 11/16/23, 11/21/23, and 11/24/23. R2's Fall Risk assessment dated [DATE] documents a score of 8 with a reference of 10 points or More = High risk Score. Under the section History of Fall Last 3 Months and answer of 0 is documented, indicating that R2 has no known history of falls. R2's Quality Improvement Review dated 02/13/24 at 12:00 AM documents: Resident (R2) was at the east nurse's station and had been sitting on her walker seat. She attempted to stand up and fell to the floor. BIMS 99 (indicating severely impaired cognition). Intervention is to encourage resident to ask for assistance from staff. On 03/07/24 at 2:00 PM, V1 (Administrator) stated, R2's Fall Risk assessment dated [DATE] is incorrect, the category History of Fall Last 3 Months documents zero falls for a point assessment of 0, she stated she can see where she has had eight falls in the last three months which would be a point value of 5, which would give her a score of 13, which would make her a high fall risk. She stated, she does not know why it got filled out incorrectly. V1 stated that R2 would not remember to ask for assistance if told to for very long because of her cognitive limitation, so the intervention of encourage R2 to ask for assistance from staff was not an appropriate intervention and R2 is already assessed as needing assistance. V1 also stated there is no documentation stating whether the physician was notified. There is no nurse's note regarding the fall on 02/13/24. R2's Quality Improvement Review dated 01/29/24 at 1:00 PM documents: Resident (R2) has very poor vision, uses a wheeled walker, takes psychotropics and antidepressants on a routine basis. She is non-compliant with asking for any assistance. She can become agitated very easily. Resident (R2) was by the east nurse's station with her walker when this event occurred. She had a skin tear to the left shin and a reddened area to the left elbow. No further complaints. She had on proper footwear but did not indicate she needed help changing positions. Intervention is to always use the wheeled walker, proper footwear and encourage her to accept staff assistance with ADL's (Activities of Daily living). She has a very poor safety awareness. R2's Nurse's notes dated 01/29/24 at 1:50 PM document: Resident (R2) had a witnessed fall at 1:00 PM R2's walker caught on furniture when trying to turn around by nurse's station and resident lost her balance resulting in fall. R2 did not hit her head. R2 has complaints of left elbow pain. There is a bruise noted and a skin tear to left shin noted. Steri-strips applied. On 03/07/24 at 2:00PM V1 (Administrator) stated, from the documentation of the fall investigation (for the fall occurring on 1/29/24), (the Quality Improvement Review) it sounds as if R2 had been using a wheeled walker, had proper footwear on, and it notes that she is non-compliant with asking for assistance. V1 stated, she does not believe there is a new intervention included on the fall investigation or an appropriate intervention. V1 stated, R2's care plan does not document any intervention for the fall on 01/29/24. R2's Quality Improvement Review dated 01/13/24 at 11:00 AM documents: This resident (R2) has poor vision, decreasing safety awareness, reluctance to ask for assistance with anything. She is on psychotropics and antidepressants. She is non-compliant with staff encouragement to allow assistance with ADL's. She can also become easily agitated and is forgetful. This event occurred in the bathroom where resident was attempting to sit on the toilet and missed. Correct footwear and interventions were in place. No injuries. BIMS 99. Intervention is to toilet her with any request as she allows assistance. R2's Nurse's notes dated 01/13/24 at 11:00 AM documents that resident (R2) was found in restroom on knees. R2 states, I hit my head. Neurological checks were initiated and were within normal limits for resident. Fall report filled out. On 03/07/24 at 2:00 PM, V1 (Administrator) stated, an intervention of toilet her with any request is not an appropriate intervention, she should be toileted upon request, and she is assessed to need assistance with toileting. V1 stated R2 has a previous intervention to have assistance with toileting. V1 stated that the fall investigation documents she is non-compliant with asking for assistance. R2's Quality Improvement Review dated 01/08/24 at 9:55 AM documents Resident (R2) has a wheeled walker, poor vision, and is on psychotropics and antidepressants. She is non-compliant with asking for help and /or accepting assistance. This event happened in the hallway while resident was using her wheeled walker. Intervention is to continue to encourage resident to accept assistance and educate staff to approach her up to five times to offer assistance. On 03/07/24 at 2:00 PM, V1 (Administrator) stated, from the Quality Improvement Review (from the fall occurring on 1/8/24) you cannot tell what happened in the fall, if there were any injuries, what the root cause of the fall was and if that intervention would be an appropriate intervention. There is no documentation of the fall on 01/08/24 in the nurse's notes. R2's Quality Improvement Review dated 11/21/23 at 6:15 PM documents: Resident (R2) was observed to fall while trying to get to bed. She had her nonskid socks on but has decreasing safety awareness. BIMS 99. The intervention is to assist her with ADL's. R2's nurse's notes dated 11/21/23 at 6:15 PM documents: V26 (Registered Nurse) was walking by R2's room and noted R2 was lying on her right side on the floor beside the bed. R2 stated, I bumped my head Small raised area noted to back of head. No other injury noted. On 03/07/24 at 2:00 PM, V1 (Administrator) stated, she does not know how the fall investigation (for the fall occurring on 11/21/23) documents that R2 was observed falling and the nurse's note documents R2 was found on the floor. V1 stated there are some discrepancies between the two accounts of the fall, she does not know why. R2's Quality Improvement Review dated 11/16/23 at 11:30 AM documents: Resident (R2) has poor vision and a decreasing safety awareness. She uses a wheeled walker. She ambulated from her room to the bathroom where she attempted to sit on the toilet seat. She missed the seat and went to the floor. She did have her nonskid socks on but is non-compliant with asking for assistance on a regular basis. Intervention is to have a therapy evaluation. R2's BIMS is 99. R2's Nurse's notes dated 11/13/23 at 2:00 AM documents: R2 fell in the bathroom trying to sit on the toilet. The aide who was helping her turned around for a pull up to help her change and R2 missed the toilet and fell on her bottom in front of the sink next to the toilet. R2 bumped her head on the toilet but has no injuries. On 03/07/24 at 2:00 PM, V1 (Administrator) stated that she does not know who the aide was, and the fall investigation (for the fall occurring on 11/13/23) does not document an aide present, the aide should not have turned around until R2 was seated, especially with R2's poor eyesight. R2's care plan documents a section for Falls with a start date of 05/12/2019 and a Goal of: Resident/responsible party will be able to state potential consequence of self-transfer/ambulation and state why still prefers self-care thru next CP (care plan) review with a date of 12/06/21. The intervention documented on 11/17/23 is Therapy evaluation, and the intervention documented on 02/13/24 is: encourage resident (R2) to ask for assistance. 3. R27's Face Sheet documents an admission date of 11/2/2022. R27's POS (Physician's Order Sheet) dated 2/1/2024 through 2/29/2024 documents R27's has been diagnosed with Hemiplegia following Cerebral Infarct affecting left side, Type 2 Diabetes Mellitus, Essential Hypertension, Need for Assistance with Care, Depression, Urinary Retention, Cognitive Impairment and Right Internal Carotid Thrombosis. R27's MDS (minimum data set) dated 11/21/23 documents R27 was assessed with BIMS (Brief Interview for Mental Status) in which R27 scored 13 out of 15 total and indicates R27 is cognitively intact. Fall Risk Assessment for R27 dated 2/15/2024 documents R27 is a high fall risk. On 3/5/2024 at 11:15am, R27 said he fell a few times at this facility. A Nurse's note in R27's medical record and dated 2/15/2024 at 7:45pm and entered by V25 (Registered Nurse/RN) documented the following: Resident yelling for son from room. Went to room, resident on floor on back with feet still up on bed. Very confused, thought he was in a car and thought son was in room. Informed NP (Nurse Practitioner) on call and orders received to send to local emergency room for evaluation. Nurse's note in R27's medical record and dated 2/15/2024 at 11:00pm documented R27 returned from the emergency room with negative CT scan (computed tomography). On 3/7/2024 at 3:00pm, V25 (Registered Nurse) said R27's psychotropic medications had been increased. V25 said on 2/15/2024, R27's psychotropic medication administration times were changed from R27 receiving Quetiapine 100mg (anti-psychotic) at bedtime to R27 receiving Quetiapine 100mg at 4:00pm. V25 said on 2/15/2024 she administered R27's Quetiapine 100mg at 4:00pm and at 5:45pm, R27 had fell. V25 said she heard R27 yelling and went to see what was going on. V25 said she seen R27 laying on the floor on his back but still had his feet up on the bed. V25 said R27 was sent to the local emergency room to be checked for injuries from his fall, but none were found and R27 was diagnosed with a urinary tract infection. Local hospital emergency room records dated 2/15/2024 document R27 was diagnosed with a urinary tract infection and did not document anything about R27 being seen for possible fall injuries. On 3/7/2024 at 10:00am, V2 (Director of Nursing) said R27 had an unwitnessed fall on 2/15/2024 and she performed the fall investigation. V2 submitted a facility form titled Quality Improvement Review and dated 2/15/24 at 1745 (5:45PM) as written documentation of the fall investigation she performed for R27's fall on 2/15/24. This form documented the following: Resident found on floor of his room. When asked what happened he told the nurse he needed to get in his car. Resident has decreased safety awareness and decreased cognitive issues. Uncooperative with BIMS (Brief Interview for Mental Status). New interventions are a floor pad and upper side rail times one. On 3/7/2024 at 10:00am, V2 said she had not considered the time change/increase of his psychotropic medication as being a factor in R27's fall on 2/15/2024. V2 said she did not have any witness statements or other investigation documentation for R27's fall on 2/15/2024 and could not produce documentation of performing root cause analysis for this fall. A facility policy titled Fall Prevention (last revision date of 11/10/18) documents the following in part: Policy is to provide for resident safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. #5 Immediately after any resident fall, the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. #6 The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an Aim for Wellness form along with any new interventions on deemed to be appropriate at the time The unit nurse will also place a new intervention on the CNA (Certified Nurse's Assistant) assignment worksheet. #7 Report all falls during morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the morning Quality Assurance meeting and any new interventions will be written on the care plan.